Revised ultrasound criteria for appendicitis in children improve diagnostic accuracy.
Goldin Adam B,Khanna Paritosh,Thapa Mahesh,McBroom Jennifer A,Garrison Michelle M,Parisi Marguerite T
BACKGROUND:Use of CT in the evaluation of suspected appendicitis in children is common. Expanding the use of US would eliminate the radiation exposure associated with CT. OBJECTIVE:We describe new criteria that improve US's diagnostic accuracy for appendicitis, making it more comparable to CT in terms of sensitivity and specificity. MATERIALS AND METHODS:We conducted a retrospective review of 304 consecutive patients undergoing US for the diagnosis of appendicitis in our institution during 2006. The sensitivity, specificity and accuracy of the maximal outer diameter (MOD) at various measurements was calculated and compared to pathology results. Additional variables (appendiceal wall thickness, fecalith, hyperemia, fat stranding, free fluid, age and weight) were also evaluated. RESULTS:The highest sensitivity (98.7%) and specificity (95.4%) were identified when MOD was ≥7 mm or wall thickness was >1.7 mm. These values resulted in correctly classifying 96.6% of cases, with 1 (0.5%) false-negative and 6 (2.9%) false-positive studies. Incorporating secondary signs of appendicitis, age or weight did not alter accuracy. CONCLUSION:These findings identify new US criteria that compare favorably to CT. In children with suspected appendicitis, using US as the initial imaging study will ultimately lead to improved accuracy, lower cost and the elimination of ionizing radiation exposure.
Radiographic features of appendiceal colic in children.
Schisgall R M
The concept of appendiceal colic was introduced in 1980 to explain the common problem of recurrent crampy abdominal pain (RAP) in children. Children with appendiceal colic often have inspissated casts of stool as foreign bodies of the appendix. The radiographic findings of 115 children operated upon for appendiceal colic have been reviewed. The radiographic features of this syndrome have included: filling defects of the appendix (83% incidence of inspissated casts of stool within the appendix); partial filling of the appendix (44% incidence of fecal casts); retained barium behind 72 h (92% incidence of fecal casts blocking egress of barium); non-visualization of the appendix (42% incidence of fecal casts); and distention of the appendix (100% incidence of fecal casts). The correlation of radiographic and operative findings will be presented. A rational approach to the radiographic workup of a child with RAP will be presented.
Elective laparoscopic appendicectomy for chronic right iliac fossa pain in children.
Panchalingam Linga,Driver Chris,Mahomed Anies A
Journal of laparoendoscopic & advanced surgical techniques. Part A
AIM:To determine whether elective laparoscopic appendicectomy is justified for chronic right iliac fossa (RIF) pain of undetermined origin. METHODS:A retrospective audit of all laparoscopic appendicectomies between January 1997 and August 2003 was performed. The expanded medical audit system (EMAS) and a Microsoft Access database of operative records were used to identify patients with chronic RIF pain subjected to elective appendicectomy. Case notes were retrieved and analysed for patient profile, duration of symptoms including clinic visits and admissions, operative findings, histological analysis, and postoperative performance. A correlation between histological findings and final outcome was investigated. RESULTS:Ninety-eight patients underwent laparoscopic appendicectomy during the period of the study. A total of 11 cases with chronic RIF pain were identified. Nine were female and 2 male. Age ranged from 9 to 14 years with a mean of 11.9 years. The number of clinic visits and admissions for chronic RIF pain ranged from 2 to 8, with a mean of 4. Duration of symptoms ranged from 1 to 36 months, with a mean of 12.1 months. Detailed history, clinical examination, and serological and radiological investigations failed to reveal the cause of the pain in all cases. Patients were followed up in postoperative clinics for between 1 and 72 months, with a mean of 16.1 months. Histology of resected appendices showed acute inflammation (3 cases), fecoliths (2 cases), lymphoid hyperplasia (LH) (1 case), LH and a foreign body reaction (1 case), LH and mucosal hyperplasia (1 case), and Enterobius vermicularis parasites in 1 case. The appendix was normal in 2 cases. Eight patients had complete resolution of RIP pain. Seven of these had pathology within the appendix and 1 was histologically normal. Two patients with resolved RIF pain, but with pain elsewhere, had lymphoid hyperplasia noted within the appendix. One patient with persistent pain 6 years postoperatively had a normal appendix. CONCLUSION:This study demonstrates that a significant number of patients with chronic RIF pain have pathology within the appendix. The majority of these cases will benefit from elective appendicectomy. It is critical however that all other possible causes of pain in the RIF are excluded. Laparoscopy is an integral part of the diagnosis and management of this particularly difficult group of patients.
The myth of the fecalith.
Maenza R L,Smith L,Wolfson A B
The American journal of emergency medicine
A radiographically demonstrated fecalith is widely considered a virtually pathognomonic sign of acute appendicitis. This case report describes a patient with a clinical presentation suggestive of appendicitis and a well-defined right lower quadrant fecalith who was found to have a normal appendix at surgery. This case calls into question the venerable dogma surrounding the fecalith and highlights the necessity for the physician to continue to rely on clinical judgment in making the diagnosis of appendicitis.
Differentiation of early perforated from nonperforated appendicitis: MDCT findings, MDCT diagnostic performance, and clinical outcome.
Kim Mi Sung,Park Hae Won,Park Ji Yeon,Park Hee-Jin,Lee So-Yeon,Hong Hyun Pyo,Kwag Hyon Joo,Kwon Heon-Ju
To determine the CT findings and assess their diagnostic performance in differentiating early perforated appendicitis from nonperforated appendicitis, and to compare therapeutic approaches and clinical outcomes between two types of appendicitis. Our retrospective study was approved by our institutional review board and informed consent was waived. From July 2012 to July 2013, 339 patients [mean age 40.8 years; age range 19-80 years; 183 male (mean age 40.5 years; age range 19-79 years) and 156 female (mean age 41.2 years; age range 19-80 years)] who underwent appendectomy with preoperative CT examination for suspected acute appendicitis were included, with exclusion of 37 patients with specific CT findings for advanced perforated appendicitis. And they were categorized into nonperforated and early perforated appendicitis groups according to surgical and pathologic reports. The following CT findings were evaluated by two radiologists blinded to pathologic and surgical findings: transverse diameter of the appendix, thickness of the appendiceal wall, the depth of intraluminal appendiceal fluid, appendiceal wall enhancement, presence or absence of focal defect in the appendiceal wall, intraluminal appendiceal air, appendicolith/fecalith, periappendiceal changes, cecal wall thickening, and free fluid. The type of surgical procedures, performance of surgical drainage, and the length of hospital stay were recorded. Univariate and multivariate logistic regression analysis were used to determine the CT findings for differentiating early perforated appendicitis from nonperforated appendicitis, a total of 75 (22%) of the 339 patients was diagnosed with early perforated appendicitis. Focal wall defect [adjusted odds ratio (aOR), 23.40; p < 0.001], circumferential periappendiceal changes (aOR, 5.63; p < 0.001), appendicoliths/fecaliths (aOR, 2.47; p = 0.015), and transverse diameter of the appendix (aOR, 1.22; p = 0.003) were independently differentiating variables for early perforated appendicitis. The transverse diameter of the appendix (≥11 mm) had the highest sensitivity (62.7%) and focal wall defect in the appendiceal wall showed the highest specificity (98.8%). The prevalence of surgical drainage was higher (p = 0.001) and the mean hospital stay was approximately one day longer (p < 0.001) in the early perforated group than nonperforated group. CT can be helpful in differentiating early perforated appendicitis from nonperforated appendicitis, although the sensitivity of the evaluated findings was somewhat limited.
Prediction Model for Failure of Nonoperative Management of Uncomplicated Appendicitis in Adults.
Kobayashi Toshimichi,Hidaka Eiji,Koganezawa Itsuki,Nakagawa Masashi,Yokozuka Kei,Ochiai Sigeto,Gunji Takahiro,Ozawa Yosuke,Hikita Kosuke,Sano Toru,Tomita Koichi,Tabuchi Satoshi,Chiba Naokazu,Kawachi Sigeyuki
World journal of surgery
BACKGROUND:Prediction of failure of nonoperative management (NOM) in uncomplicated appendicitis (UA) is difficult. This study aimed to establish a new prediction model for NOM failure in UA. METHODS:We included 141 adults with UA who received NOM as initial treatment. NOM failure was defined as conversion to operation during hospitalization. Independent predictors of NOM failure were identified using logistic regression analysis. A prediction model was established based on these independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were used to assess the discrimination and calibration of the model, respectively, and risk stratification using the model was performed. RESULTS:Among 141 patients, NOM was successful in 120 and unsuccessful in 21. Male sex, maximal diameter of the appendix, and the presence of fecalith were identified as independent predictors of NOM failure for UA. A prediction model with scores ranging from 0 to 3 was established using the three variables (male sex, maximal diameter of the appendix ≥ 15 mm, and the presence of fecalith). The area under the ROC curve for the new prediction model was 0.778, and the model had good calibration (P = 0.476). A score of 2 yielded a sensitivity of 71.4% and a specificity of 90.8%. Patients were stratified into low (0-1), moderate (2), and high (3) risk categories, which had NOM rates of 5.2%, 47.1%, and 77.8%, respectively. CONCLUSIONS:Our prediction model may predict NOM failure in UA with good diagnostic accuracy and help surgeons select appropriate treatments.
Ultrasonographic findings identifying the faecal-impacted appendix: differential findings with acute appendicitis.
Park N H,Park C S,Lee E J,Kim M S,Ryu J A,Bae J M,Song J S
The British journal of radiology
The aim of this study was to identify ultrasonographic findings that show the normal faecal-impacted appendix, in order to avoid unnecessary surgery via a misdiagnosis of acute appendicitis. Of 160 patients who underwent ultrasonography between January 2004 and July 2005 for right lower quadrant pain, 22 cases (including 7 cases confirmed pathologically and 15 confirmed clinically and on follow-up ultrasonography) were diagnosed as a normal faecal-impacted appendix. The criteria that we used to distinguish a faecal-impacted appendix from acute appendicitis include preservation of the normal wall layering of the appendix, maximum mural thickness, presence of peri-appendiceal fat infiltration and increased blood flow in the appendiceal wall. The maximum measured outer diameter of a normal faecal-impacted appendix was 0.54-1.03 cm, with a mean diameter of 0.68 cm. The maximum mural thickness ranged from 0.08 cm to 0.26 cm, with a mean thickness of 0.15 cm. The normal wall layers of the appendix were preserved and no evidence was seen of peri-appendiceal fat infiltration in any case. No demonstrably increased blood flow in the appendiceal wall was observed. In conclusion, faecal impaction increases the outer transverse diameter of the normal appendix, frequently leading to a misdiagnosis of acute appendicitis. Recognition of preservation of the normal layering of the appendiceal wall, smaller maximal outer diameter, thinner maximal mural thickness, the absence of peri-appendiceal mesenteric infiltration and no demonstrably increased blood flow in the appendiceal wall should help to prevent unnecessary surgery.
Appendiceal faecaliths are associated with right iliac fossa pain.
Grimes Caris,Chin Diana,Bailey Catherine,Gergely Szabolcs,Harris Adrian
Annals of the Royal College of Surgeons of England
INTRODUCTION:There is debate over whether a normal-looking appendix should be removed at diagnostic laparoscopy performed for right iliac fossa (RIF) pain. Faecaliths are associated with appendicitis. This study assessed whether there was an association between the removal of normal appendices containing faecaliths and improvement of symptoms. PATIENTS AND METHODS:Analysis of the histology database for all appendicectomies during 2003-2007 with normal histology, noting presence of a faecalith. Retrospective study using a telephone questionnaire for frequency/duration of pre-operative symptoms, postoperative symptom recurrence, re-admission rates and complications. The faecalith-positive (f(+)) group was compared to a similar control group of patients who had a normal appendix removed which did not contain a faecalith (f(-)). RESULTS Out of 203 appendicectomies performed with normal histology, 26 (13%) were f(+). Of these, 21 responded to the questionnaire. Thirty-one consecutive patients with normal histology and no faecalith were identified. A similar proportion in each group presented with three or more episodes of pain prior to appendicectomy (38% f(+); 39% control). Only one (5%) of the f(+) patients had recurring symptoms after the operation, compared with 14 (48%) of the control group (P = 0.0016). Only one (5%) of the f(+) patients underwent further investigations, compared with 11 (36%) of the control group (P < 0.02). None of the f(+) patients were re-admitted, compared to 19% of the control population. There were no significant postoperative complications in either group. CONCLUSIONS:Appendiceal faecaliths may be a cause of right iliac fossa pain in the absence of obvious appendiceal inflammation. In this study, the policy of routine removal of a normal-looking appendix at laparoscopy in the absence of any other obvious pathology appeared to be an effective treatment for recurrent symptoms in those cases with a faecalith. Further studies are needed to assess this putative association.
Retrocecal appendix location and perforation at presentation.
Herscu Gabriel,Kong Allen,Russell Dylan,Tran Cam-Ly,Varela J Esteban,Cohen Allen,Stamos Michael J
The American surgeon
Retrocecal appendicitis has been theorized to follow a more insidious course than other anatomic variants. To determine the influence of retrocecal anatomy on clinical course of appendicitis, 200 adult patients treated at a major university medical center with the diagnosis of appendicitis from 2001 to 2004 were retrospectively studied. Computed tomography (CT) scans of adult patients with an ultimate diagnosis of appendicitis were analyzed to determine an association between retrocecal appendix and perforation of the appendix at presentation. A higher perforation rate in the retrocecal group would imply patient delay in presentation from more tolerable symptoms. CT scans were examined for retrocecal location and perforation. No significant association was found between retrocecal anatomy and perforation rates at presentation (chi-square = 2.1, P = 0.15, odds ratio = 1.6, 95% confidence interval [0.8-3.0]). However, the risk of perforation was 60 per cent higher in the retrocecal group. By regression analysis, age and the presence of a fecalith on CT scan were predictors of appendix perforation. Appendix location was not. In this study, we found no significant association between retrocecal appendix anatomy and perforation at presentation.
[Chronic appendicitis due to multiple fecaliths. A case report].
Montiel-Jarquín Álvaro José,Ramírez-Sánchez Celso,García-Cano Eugenio,González-Hernández Nicolás,Rodríguez-Pérez Fabiola,Alvarado-Ortega Ivan
Cirugia y cirujanos
BACKGROUND:The appendix inflammatory process is the most common cause of chronic abdominal pain in the right lower quadrant. The frequency of appendiceal lumen obstruction by fecalith ranges from 10 to 20%; few cases of obstruction by multiple fecaliths had been reported. CLINICAL CASE:Sixty-nine years old male, diabetic and hypertensive in control, he underwent bowel resection 30 years previously. He completed 6 months with intermittent, mild pain in the right lower quadrant abdomen; 14 days prior to admission with increasing pain, nausea, vomiting, constipation, abdominal distension and absence of peristalsis; 12,750 leukocytes, neutrophils 90%; plain abdominal radiography without specific bowel pattern, TAC with 3 dense images in right lower quadrant; exploratory laparotomy was performed and perforated appendix with 3 free fecaliths was found. Histopathological report showed fibrosis and lymphocytic infiltrate in the muscle layer of the cecal appendix consistent with chronic appendicitis. CONCLUSIONS:The most common obstruction of the appendix lumen is by a single fecalith. In this case the patient had chronic appendicitis secondary to appendiceal lumen obstruction by multiple fecaliths. Reviewing the international literature any case of chronic appendicitis associated with the presence of multiple fecaliths was found.
Size matters: Computed tomographic measurements of the appendix in emergency department scans.
Moskowitz Eliza,Khan Abid D,Cribari Chris,Schroeppel Thomas J
American journal of surgery
BACKGROUND:Radiologists use a size cutoff in appendiceal diameter to assist surgeons in diagnosing appendicitis, however, no consensus exists as to the size of a normal adult appendix. We aim to evaluate radial appendiceal diameter on CT in adult patients both with and without appendicitis. METHODS:Retrospective review of adults who underwent abdominal CT was performed. Variables collected include: demographics, BMI, WBC count at presentation, radial diameter of appendix (mm), presence of fat stranding, fecalith, and free fluid. RESULTS:During the study period, 3099 patients underwent CT. The appendix was visualized on 74% of scans. Mean appendiceal diameter was 6.6 mm (±1.7). The appendix was larger in patients with appendicitis (6.6 vs. 11.4; p < 0.0001). Overall appendectomy incidence was 3.2%. Sensitivity and specificity of CT in diagnosing appendicitis in this cohort of patients were 90% and 94%. NPV was 99.5%. CONCLUSION:While appendiceal diameter was larger in patients with appendicitis, >20% of patients without appendicitis had an appendiceal diameter >7 mm. Diameter alone should not be relied upon to diagnose appendicitis.
Appendiceal fecalith is associated with early perforation in pediatric patients.
Alaedeen Diya I,Cook Marc,Chwals Walter J
Journal of pediatric surgery
PURPOSE:A fecalith is a fecal concretion that can obstruct the appendix leading to acute appendicitis. We hypothesized that the presence of a fecalith would lead to an earlier appendiceal perforation. METHODS:Between January 2001 and December 2005, the charts of all patients younger than 18 years old who underwent appendectomy at our institution were reviewed. Duration of symptoms and timing between presentation and operation were noted along with radiologic, operative, and pathologic findings. RESULTS:There were 388 patients who met the study criteria. A fecalith was present in 31% of patients (n = 121). The appendix was perforated in 57% of patients who had a fecalith vs 36% in patients without a fecalith (P < .001). The overall rate of interval appendectomies was 12%. A fecalith was present on the initial radiologic studies of 36% of the patients who had interval appendectomies, and the appendix was perforated significantly sooner in these patients when compared to those without a fecalith (91 vs 150 hours; P = .036). CONCLUSION:The presence of fecalith is associated with earlier and higher rates of appendiceal perforation in pediatric patients with acute appendicitis. An expedient appendectomy should therefore be performed in the pediatric patient with a radiologic evidence of fecalith.
Fecalith in the Proximal Area of the Appendix is a Predictor of Failure of Nonoperative Treatment for Complicated Appendicitis in Adults.
Ando Tomofumi,Oka Taishu,Oshima Go,Handa Kan,Maeda Shingo,Yuasa Yuji,Aiko Satoshi
The Journal of surgical research
BACKGROUND:The management of complicated appendicitis remains controversial, since this disease has various clinical presentations and is associated with high rates of adverse events. Although initial nonoperative treatment is generally employed for complicated appendicitis, its clinical presentation and the predictors of nonoperative treatment failure are unclear. METHODS:Patients diagnosed with complicated appendicitis in our hospital between April 2015 and March 2020 were enrolled. In total, 113 patients were classified into three categories: emergency appendectomy, failure of nonoperative treatment and successful nonoperative treatment. The primary outcome was the rate of failure of nonoperative treatment, as assessed by logistic regression analysis. The secondary outcomes were the operative procedures and postoperative courses of the three groups. RESULTS:Of 113 patients, 45 (40%) underwent emergency appendectomy, 25 (22%) failed nonoperative treatment, and 43 (38%) had successful nonoperative treatment. Among these successful cases, 38 patients (88%) underwent interval appendectomy. In multivariate analyses, the presence of a fecalith in the proximal area of the appendix was an independent risk factor for failure of nonoperative treatment (odds ratio, 20.5; 95% confidence interval, 4.37-95.7, P < 0.001). Postoperative outcomes were more unfavorable in cases of failed nonoperative treatment than in cases of emergency and interval appendectomy. CONCLUSIONS:The presence of a fecalith in the proximal area of the appendix is an independent predictor for failure of nonoperative treatment for complicated appendicitis in adults. Patients with this risk factor should be considered candidates for surgical treatment.
Association between the appendix and the fecalith in adults.
Ramdass Michael J,Young Sing Quillan,Milne David,Mooteeram Justin,Barrow Shaheeba
Canadian journal of surgery. Journal canadien de chirurgie
BACKGROUND:We sought to determine the association between the presence of a fecalith and acute/nonperforated appendicitis, gangrenous/perforated appendicitis and the healthy appendix. METHODS:We retrospectively analyzed appendectomies performed between October 2003 and February 2012. We collected data on age, sex, appendix histology and the presence of a fecalith. RESULTS:During the study period, 1357 appendectomies were performed. Fecaliths were present in 186 patients (13.7%). There were 94 male (50.5%) and 92 female patients, and the mean age was 32 (range of 10-76) years. The fecalith rate was 13%- 16% and was nonexistant after age 80 years. The main groups with fecaliths were those with acute/nonperforated appendicitis (n = 121, 65.1%, p = 0.041) and those with a healthy appendix (n = 65, 34.9%, p = 0.003). The presence of fecaliths in the gangrenous/perforated appendicitis group was not significant (n = 19, 10.2%, p = 0.93). There were no fecaliths in patients with serositis, carcinoid or carcinoma. CONCLUSION:Our data confirm the theory of a statistical association between the presence of a fecalith and acute (nonperforated) appendicitis in adults. There was also a significant association between the healthy appendix and asymptomatic fecaliths. There was no correlation between a gangrenous/perforated appendix and the presence of a fecalith. The fecalith is an incidental finding and not always the primary cause of acute (nonperforated) appendictis or gangrenous (perforated) appendicitis. Further research on the topic is recommended.